Subclavian Puncture

This is a variation of the technique used by anesthetists to access the subclavian vein. The anesthetists approach the vein starting high up in the delto-pectoral groove aiming along the clavicular shaft – this makes the skin puncture site near the clavicle but we need it further below at the top of the future pacemaker pocket.

Therefore the skin puncture is done as shown at the hollow of the delto-pectoral triangle, about 1-2 finger-breadths below from the clavicle at its junction between the middle third and lateral third (roughly at its “bend”). It should be realized that the needle will be traveling through the upper aspect of the pectoralis major muscle (through its clavicular head)

The puncture needle is slowly advanced towards the shaft of the clavicle (at about an 20-30 degree angle to the skin) and once it hits the clavicle, the needle is slightly withdrawn and angulated (increased angle of attack to skin surface ) more so that the tip is under the clavicle. Then, the direction of the needle is changed so that now the tip aims towards the supra-sternal notch. The needle is slowly advanced in that direction (now at a skin angle of 20 – 30 degrees) with gentle suction to see whether it punctures the vein – whence dark venous blood would be aspirated. Once blood is aspirated, the needle is steadied and liberal aspiration of blood is done to ensure good access in to the vein. Thereafter the syringe is removed and guide-wire advanced in to the lumen.

Subclavian Puncture Steps :

Step 1
Step 2
Step 3
Step 4
Step 5